The next deadly epidemic is here, and our culture of convenience may be the culprit / Mary J. Loftus

More die of food than famine, cautions the proverb, and surely in America this is so. The national girth has increased dramatically during the past several decades—as have obesity-related health problems. According to the Centers for Disease Control and Prevention (CDC), about two-thirds of American adults are now overweight and about one-third are obese.

A corresponding rise in diabetes has even prompted researchers to coin a new hybrid term: diabesity.

“There is an epidemic going on that, if left unchecked, will have a huge effect on the U.S. population and on health care costs,” says Hubert Professor of Global Health and Epidemiology K. M. Venkat Narayan, who came to Emory last year from the CDC’s Division of Diabetes Translation. “The numbers are very worrying.”

The CDC now predicts that 48.3 million Americans will have diabetes by 2050, nearly triple the number living with diabetes today. This new projection shocked even diabetes researchers, who had predicted much lower figures just a few years ago.

What appears to be at fault, ironically, is the pervasive ease and convenience of the modern lifestyle, both in the sheer abundance of food and the passive avoidance of exercise.

Americans, who spend half their food budgets eating out, are surrounded and seduced by culinary delights that sing a siren song at every restaurant-laden corner. Fast food or gourmet food, chain or bistro, ethnic or fusion, it has never been easier to indulge every craving, nearly instantaneously.

Portion sizes have increased exponentially. A study published in the American Journal of Public Health found that since the 1970s, the size of cookies has increased by 700 percent, muffins by 333 percent, steaks by 224 percent, and bagels by nearly 200 percent. Servings of sodas, burgers, and fries are two to five times larger.

Grocery store shelves are stocked with every conceivable tempting treat or take-home dinner—an entire row of chips and dips, family-size frozen lasagna, deli muffins with tops like flying saucers. Indeed, any high-end food one desires, from ice cream to ribs, can be ordered online and delivered to the doorstep.

And driving is exactly what Americans are doing. Walking or biking has taken a back seat to the convenience of cars. Even when not sitting behind the wheel, people are sitting in front of televisions and computers, at home and at work. More than one-quarter of American adults report being “completely sedentary,” according to the CDC.

More calories in, less energy out makes for a catastrophic equation, says Vice President for Academic Health Affairs Jeff Koplan, and this spreading epidemic of diabesity isn’t limited to the United States but is showing up in other countries as well. For the first time, more people globally are overweight than underweight—nearly half a billion people worldwide are considered overweight or obese.

“When you look at the spread of obesity and the higher
proportion of the population that has diabetes, it looks like an infectious disease,” says Koplan, recently named director of Emory’s new Global Health Institute. “It meets the definition of an epidemic: an unexpectedly larger number of cases than you thought would occur.

“If you would have asked me in 1996 or 1997, what’s going to happen, I’d have said, it can’t get any bigger. It’s going to taper; we’re going to have a plateau. With each year it has gone up. This is an absolutely unpredictable phenomenon in public health.”

The obesity-diabetes link is clear: rates of diabetes Type 2 increase with higher weight and limited exercise. “Someone with a body mass index (BMI) of thirty-five or more has a six times higher chance of developing it than someone normal in weight,” Koplan says. “Throughout history, Type 2 diabetes has been seen only in adults. Now we’re seeing it in children.”

In diabetes, the body doesn’t produce or properly use insulin, a hormone necessary for converting sugars, starches, and other foods into energy needed for daily life. Both genetic and environmental factors appear to contribute to the disease, although its exact cause remains a mystery.

A full 12 percent of the U.S. population may have Type 2
diabetes by 2050 if trends don’t start to reverse. If these levels are reached, it would take an extraordinary toll on the country in terms of death and disability, says the CDC, through the disease’s acute and chronic complications.

Diabetes can lead to kidney disease, heart disease, blindness, nerve damage, amputation, and premature death. “Nearly every system in the body is affected,” Narayan says.

Initial treatments for Type 2 diabetes include changes in diet and weight loss. This can restore insulin sensitivity even when the weight loss is modest, such as ten to fifteen pounds. The next step is antidiabetic drugs; if these fail, insulin therapy may be necessary.
Diabetes can be extremely damaging, but it is not always obvious. A third of people with diabetes don’t even know they have the disease, since it can be asymptomatic or its symptoms—frequent urination, excessive thirst, extreme hunger, unexplained weight loss, increased fatigue, blurry vision, or irritability—are often ignored or attributed to other causes.

“Patients can only be directed to risk-reduction programs if they are identified early,” says Professor of Medicine Lawrence Phillips of the Division of Endocrinology, which has been awarded $2.9 million by the National Institute of Diabetes, Digestive, and Kidney Diseases to develop a procedure to detect prediabetes. “We hope screening for prediabetes will soon be as common as screening for cancer through mammograms or prostate cancer exams.”

Such screenings might prevent the leading cause of new cases of blindness among adults. Ophthalmologists at the Emory Eye Center routinely treat patients who have had their vision affected by diabetes. Diabetic retinopathy is a complication that can weaken the retina and block or blur vision by causing abnormal blood vessels to form in the back of the eye. These vessels can leak fluid into the vitreous humor or distort or detach the retina.

People who have had diabetes for fifteen years or more are at much higher risk for developing this sight-stealing disease, which ophthalmology professor Thomas Aaberg says “is preventable and very treatable with continuous medical treatment and a yearly exam by an ophthalmologist.”

Because diabetes is especially dangerous if not caught early and treated appropriately, the burden of the disease disproportionately falls on the poor, the medically underserved, and minorities. Narayan’s team predicts that diabetes will increase by 481 percent among Hispanics, 208 percent among blacks, and 113 percent among whites during the next several decades.

Nevertheless, Narayan and other public health experts remain hopeful that the diabesity epidemic can be curtailed, much as smoking has been.

Smoking rates have declined steadily for the past twenty years in the U.S., and Americans smoked fewer cigarettes last year than at any time since 1951—the result of an aggressive public health campaign that included higher costs for cigarettes, advertising restrictions, and a shift in public perceptions as the dangers became widely known.

A similar set of tactics must be used to battle obesity and diabetes, Narayan says. “Lifestyle changes have proven very, very successful. Knowing the right answer is only half the challenge. Knowing how to get that answer implemented through human nature—that’s the much harder other half.”

Diet and dance were the answers for fourteen-year-old Imani Lesane, a high school freshman at Clarkston High. When she became constantly thirsty last year, drinking anything in sight, Imani did some research and discovered this was a symptom of diabetes. Told that she was “too young to worry about that,” Imani still insisted that her mother take her to the doctor, where she was diagnosed with Type 2 diabetes and was referred to Emory for treatment.

As a member of a dance troupe, Imani has always been active, but was still overweight. After her diagnosis, the 5' 1'' ninth-grader, with the help of an Emory nutritionist and diabetes educator, cut down on junk food, upped her exercise routine, and lost more than forty pounds—dropping from 180 to 138. “It was difficult, but everybody was giving me compliments,” she says. “I look back at my old jeans and old pictures, and I’m just like whoa, I did lose a lot of weight.”

“Imani doesn’t drink any regular soda, no juice, no sugar, no salt, no fried foods. She cut out her potato chips that she used to love,” says her mom, Jamala Lesane. “Every six months or so, she’ll treat herself to fried chicken or hot fries. Her diet has completely changed. Now it’s a regular routine for her. Whatever food other people are eating around her, it doesn’t phase her. She’s very disciplined.”

Imani was profiled by Emory neurosurgeon and CNN journalist Sanjay Gupta on his health broadcast, House Call with Dr. Sanjay Gupta, as a success story—a teenager who is controlling her diabetes through a healthier lifestyle.

“This isn’t breaking news, we’ve been talking about this for quite some time, just how bad the overweight and obesity problem is getting among children. We are starting to see some catastrophic health problems in very young children. . . . it’s still getting worse,” says Gupta.

Seventeen percent of American youth are obese, and nearly twenty percent are predicted to be obese by 2010, according to a new report by the Institute of Medicine (IOM). One in five kids, then, will face obesity-related health risks. Koplan, a former director of the CDC, chaired the IOM Obesity Report Committee.

“This is a big, big problem,” he says. “If we don’t address it, we’re going to be paying the price for it in disease, premature death, and dollars for many years to come.”

Koplan gave the presentation “Preventing Childhood Obesity: Health in the Balance” to Emory alumni in London as part of the Emory Cares International Service Day on November 11. Alumni made donations of clothing and goods to Oxfam and became informed about obesity, which is reaching epidemic proportions in England as well.

“We tend to read articles in the paper that try to place the blame on one item,” Koplan says. “It’s fast food. If we just get rid of McDonald’s, Burger King, Pizza Hut,
or whatever, we’d be okay. Or it’s vending machines. Or carbonated sweetened beverages. But Sir Isaac Newton had it right—energy in equals energy out.”

Take in a certain number of calories, whether a Mars bar or a bag of chips, he says, and you have to expend those calories or they transform into fat.

“Our mothers had it right a while ago: Eat your veggies
and get out of the house and go play,” he says. “These weren’t options; they were orders.”

Staying afloat in a sea of soda may be a difficult proposition, however. A fast-food lifestyle and increased consumption of soft drinks, says Koplan, have definitely been contributing factors for obesity in both adults and children. Soda consumption in America has doubled since 1970 to more than forty-four gallons per person per year.

“There are eight to ten thousand new products in supermarkets every year, and these are not new types of lettuce and tomatoes,” Koplan says. “They are processed foods—high in calories, fat, sugar. Many are designed to be consumed on the go, not for a leisurely meal at rest.”

When Indian physicist and food activist Vandana Shiva
spoke at Emory in October on building a “food democracy,” she said that people are actually suffering from a “malnutrition of the wrong kinds of foods. Obesity is linked to nonfoods. We’re eating things not worthy of being eaten.”

Obesity-related illnesses take a high toll, both human and financial. The impact of obesity and diabetes on medical spending has been substantial, says Robert W. Woodruff Professor Ken Thorpe, chair of the Department of Health Policy and Management in the Rollins School of Public Health. “Once people are sick, we’re doing a better job at treatment,” Thorpe says. “The bad news is that we have larger shares of the population who are sick.”

The risk of developing not only diabetes, but gallstones, hypertension, heart disease, stroke, and some forms of cancer is higher for people who are obese, Thorpe says, and health care costs are about a third more than for people of normal weight. Additional health care costs resulting from the decline in health, he says, totaled $70 billion last year.

“We’ve been trying to get the debate focused on more effective interventions,” says Thorpe. “We need to aim for around 2,000 calories a day—less trans fat and processed foods, more fresh fruits and vegetables, less snacking between meals. What are the policy levers we can use to change the composition of what we eat at home, work, and school?”

For example, Thorpe would like to see restaurant menus list calories, trans fats, and nutritional content for each item so diners can make informed choices.

The media, he says, are getting better at showing the link between obesity and health concerns, and movies such as Supersize Me and Fast Food Nation have had an impact: “At least we’re seeing apples and fruits showing up in kids’ meals instead of just french fries.”

Schools, though, which are especially important as partners to combat adolescent obesity and teach appropriate lifelong eating habits, have been so focused on academics that there has been little emphasis on health and exercise.

Thorpe has an insider’s view of policy matters related to reducing obesity—he served as deputy assistant secretary for health policy in the U.S. Department of Health and Human Services from 1993 to 1995, coordinating all financial estimates and program impacts of President Clinton’s health care reform proposals for the White House.

As a survivor of heart bypass surgery, Bill Clinton is still a staunch advocate of Thorpe’s vision: he selected reducing childhood obesity as one of his foundation’s major initiatives, quoting an Emory study showing that obesity alone accounted for 25 percent of the increase in health care costs during the last fifteen years.

“I thought it was a chance where I could save the most lives . . . do the most good, and also do something that I understood from my own experiences,” Clinton told CNN. “I was the fat band boy.”

Clinton and the American Heart Association have joined forces in an attempt to stop the increasing prevalence of childhood obesity in the U.S. by 2010.

Lab experiments have shown that animals are adept at regulating a steady body weight until they are placed in a situation in which high-fat, high-sugar food is constantly available. Under these conditions, the animals overeat and become far heavier.

Placing teenagers in environments where soda machines are available in schools, little exercise is required, and high fat, high-processed foods are available 24/7 is simply a large-scale model of this same experiment, say public health experts.

Walkable neighborhoods, healthier school lunches, flexible work hours that allow time to exercise, nutritional education, and health marketing slogans are all being touted as ways for the population to tone up and slim down. Assistant Professor Anne Dunlop in the School of Medicine has received a $425,000 grant from the CDC Foundation to develop “Let’s Get Fit, Kids!” to help urban, African American children who are obese or at risk achieve a healthier body weight. Behavior patterns spread rapidly, says Narayan. Groups as large as an entire country or as small as one family can set the tone for a healthier lifestyle.

“My mother, who turns seventy next year, now lives with us. By her example over the years, our own diets have changed,” says Narayan, who was born and raised in Bangalore, India, and eats vegetarian cuisine at home. “It’s traditional Indian cooking, but we tend to adapt it to be low fat, and we use a lot of olive oil. We also eat lots of fruits and vegetables.”

Three generations of the Narayan family, including his mother, wife, and nine-year-old daughter, Sarayu, often gather around the table to enjoy chappathi bread, lemon rice, dhal lentils cooked in spices, fresh olives, walnuts, apples, mangoes, and tea, joined together by the ancient, reassuring ritual of a communal meal.